Certification

I ___ acting for ___ of ___ hereby declare that to the best of my knowledge and belief this claim is true, correct, complete and substantiated by claimant's records.

Date

Signature

For CBSA use only

Record of payment

Date interest begins

Total

22. Customs duties

23. Tax

GST

Other

24. Other duties

CBSA use only

Official coding

25. Customs duties - 9019

Payment $

Adj. to payment $

26. Anti-dumping/countervailing duties - 9018

Payment $

Adj. to payment $

27. Import excise tax – 9409

Payment $

Adj. to payment $

28. Other duties

Payment $

Adj. to payment $

29. GST

Payment $

Adj. to payment $

30. Sub-total

Payment $

Adj. to payment $

31. Interest

Payment $

Adj. to payment $

32. Total

Payment $

Adj. to payment $

Privacy Statement

The information you provide in this document is collected under the authority of Sections 89 to 115 of the Customs Tariff, Section 23 of the Financial Administration Act, Section 70 of the Excise Tax Act and Section 173 of the Excise Act, 2001, for the purpose of determining the eligibility for Drawback duties and taxes paid. The information may be disclosed to the Canada Border Services Agency (CBSA) - Programs Branch for the purposes of program evaluation, security and reporting purposes. Client information may also be disclosed to the Canada Revenue Agency (CRA) for the purposes of locating an individual in order to collect a debt owing to Her Majesty in Right of Canada. The information may also be disclosed to the Royal Canadian Mounted Police (RCMP) and/or to investigative bodies specified in the Privacy Regulations - upon the written request - for the purposes of law enforcement/investigation.

Under the law, failure to provide the information requested on this form may result in the rejection of the application. Individuals have the right of access to and the protection and correction of their personal information under the Privacy Act - Section 12.

10. Import Transaction No. - Enter the number of the customs office transaction number appearing on the import entry Form B3. (3 digits) and the transaction number (14 digits).
* Indicate K32A , in reference to the form, where applicable.

11. Date of release - Indicate the date the goods were released from customs.